Q. I’m 55 and in my ninth year as a T4 complete paraplegic. I’m at an age where the subject of colonoscopies and PSA (test for prostate cancer) come up among my nondisabled friends. However, when I visit my primary care doc, my visits are preoccupied with issues related to spinal cord injury, and these types of tests are never mentioned.
How important are cancer screenings? Seems like I broke my back, so what else can go wrong? Also, I’m now on Medicare — does it cover these screenings? If so, how do I go about setting them up with my physician?
A. Gene, you bring up an important point. For answers I turned to Dianna Elledge, RN, of the Craig Hospital Nurse Advice Line. She explains that wheelchair users spend so much time concentrating on the health issues that accompany SCI that screenings for common types of cancers — many of which are very treatable when caught early — can get overlooked. This isn’t just a subject for middle age; both men and women should start screening for certain types of cancers in their late teens. “One big issue in these screenings is the lack of sensation that comes with SCI may prevent a person from sensing when something is wrong,” says Elledge. “Another issue is a lack of accessible machines and offices.”
The good news for people on Medicare is the plan includes a “Yearly Wellness Exam,” which has no copay — this is important because other insurance carriers frequently follow Medicare’s lead in reimbursement. A caveat on Medicare: Be sure you are being seen for a “Wellness Exam” and not a “physical,” which will have a copay. Medicaid also covers various types of annual tests and health screenings, although it varies state by state.
It is up to each of us to ask our physicians about which health screenings we should have. “Your most important tool to ensure these screenings are done is communication with your doctor — ask them about specific tests and how often you should have them,” says Elledge.
Here is a brief overview of important cancer screenings to ask your primary care doctor about. All of these screenings are 100-percent covered under Medicare as part of scheduled Wellness screenings. In addition to health reasons, it is important to ask your doctor about these screenings for financial reasons. There is no copay when these screenings are done as part of the Medicare screening schedule, but Medicare charges a 20 percent copay if the tests are run for diagnostic purposes to explain specific symptoms.
For men, prostate cancer screening is important. According to a study in the 2004 issue of Urology, there is good news and bad news. The study found the incidence of prostate cancer was less in men with SCI than in nondisabled men, but the bad news is prostate cancer was detected later, meaning it was more advanced when it was diagnosed in men with SCI. The article attributes this to decreased prostate screening among the SCI population. This is why men should ask their physician about getting screened for prostate cancer with a PSA test (for prostate-specific antigen). According to the American Cancer Society, men should start taking a PSA test at age 50, or 45 for African Americans and/or men who have a first-degree relative (father, brother or son) who has been diagnosed with prostate cancer before age 65. The lower the PSA score the better. If your PSA is 2.5ng/mL or less, the ACS recommends a repeat PSA every two years; for a reading higher than 2.5, screening should be repeated every year. The ACS also recommends a digital prostate exam — for wheelchair users this is done while you are lying prone on an exam table. Under Medicare there is a 20 percent copay for the digital rectal exam.
Another important exam men should do is a monthly testicular self-exam, starting around age 17, explains Paula Wagner, a urology nurse practitioner at UC Davis Medical Center in Sacramento, California. Ideally do this during or right after a warm bath or shower when the skin that covers the testicles is relaxed. When you do the exam, your testicles should feel like rubber balls with no unusual lumps or bumps; any unusual lump or bump should be brought to the attention of your physician. Quads who don’t have the ability to do a self-exam should ask a significant other or personal care attendant to do it for them. Doing a self-exam is especially important because a lump on a testicle is usually the first sign of testicular cancer. In addition, another early sign is a dull ache in the lower abdomen or groin, something people with SCI who don’t have sensation will miss.
For women, a pap smear, used to screen for cervical cancer, is an important test. According to the Mayo Clinic, women should begin pap testing at age 21 and it should be repeated every three years until age 65. This is another type of cancer where lack of sensation could mask early signs that include pain during or after intercourse and low abdominal pain. “The biggest challenge for gynecological exams is transferring to the exam table itself,” says Elledge. She says communicating your needs is critical, as is arranging for clinic staff to have a couple of assistants transfer you to the exam table. Some women, especially if they have severe spasticity, also require assistants to help stabilize them during the exam. Another option? If you drive a power chair with recline, your gynecologist can do the exam in your chair in the recline position.
Another important screening test for women is a monthly breast self-exam starting at age 20, because breast cancer is the most common cancer among women. Although SCI does not increase the risk of breast cancer, certain aspects of SCI, including reduced sensation and or reduced arm and hand movement, can make early detection more difficult, according to Craig Hospital’s education module, Breast Cancer and SCI. To self-exam, start with using a mirror to look for lumps, changes in breast shape or unusual pain, or discharge from the nipple. Then, palpate, using your fingers to feel your breasts in overlapping areas. In addition, be sure to check upper chest areas and underarms. Most breast lumps are found this way or by a woman’s significant other. If you are not able to do a self-exam, have a significant other or caregiver assist you.
Another step in the screening process for breast cancer is getting a mammogram — American Cancer Society guidelines suggest starting at age 40 and getting one annually from 45-54, then every two years after age 55. Elledge says mammograms used to be a lot more difficult for wheelchair users because the machines are set for standing, but more and more facilities are getting mammogram machines that are wheelchair accessible, and she suggests asking your physician if there is an accessible one in your area.
Last but not least is a colonoscopy to check for colon cancer. Although having SCI doesn’t put a person at increased risk of colon cancer, again it is a test that can be missed by your physician unless you ask for it — and according to the American Cancer Society you should ask for one starting at age 50 and do a follow-up every 10 years. For more on colonoscopies, including options for “cleaning out and prepping,” see “Preparing for a Colonoscopy after Paralysis” in resources.
The bottom line is the screening tests described here are for common cancers that are extremely treatable if caught early. The key is to be the squeaky wheel and ask your physician about the tests. Hopefully the results will be negative, which is a great feeling. If not, the sooner you catch cancer, the more treatment options you will have — and the higher the likelihood of a beneficial outcome.
• Breast Cancer and SCI, craighospital.org/resources/breast-cancer
• Craig Nurse Advice Line, 800/247-0257
• How to Do a Testicular Self Examination, tcrc.acor.org/tcexam.html
• Medicaid Benefits: Diagnostic, Screening and Prevention Services, kaiserf.am/2rwX17I
• Medicare Preventive visit, screenings & yearly wellness exams, www.medicare.gov/coverage/preventive-visit-and-yearly-wellness-exams.html
• Preparing for a Colonoscopy after Paralysis, www.newmobility.com/2012/10/preparing-for-a-colonoscopy-after-paralysis/